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Monday, December 31, 2007

During one's medical training, the subject of organ transplantation becomes inescapable. For myself, I've encountered it at least twice, both during my two weeks on the liver transplant team, as well during my month on the renal service during my internal medicine rotation when I went to the transplant clinic. On the surface of it, organ transplantation is one of the great successes of modern medicine as well as seemingly straightforward ethical proposition. However, after closer examination it becomes clear that organ transplantation, while still being a net positive, is not as straightforward as one would like it to be.

The article "Desperately Seeking a Kidney" in the NYTimes highlights many of the main issues. The article is written by a psychiatrist who was seeking a kidney transplant. She describes what led her to be a candidate for organ transplantation, her time on the waiting list, her quests to solicit family, friends, and eventually strangers for a donation, and how the process affected both her and her potential donors. As medical students, we often deal with science of transplation, such as the immunology behind organ rejection, and the pharmacology

Organ transplantion is encouraged by many groups, often as the "gift of life." And while I still believe that organ donation is a positive action and should occur, I must confess my own misgivings about the process, especially given the experience in the article above. In my mind, the ideal solution would involve using stem cells or some other synthetic process to provide a replacement organ, making donation virtually obsolete. Of course, this is not reality (yet, anyway). So, we are left with donation as it is. As the author discusses, in the U.S., organ donations are "gifts" by definition, as there is no other legal way to obtain an organ. However, this leads to the "tyranny of the gift," as she describes: the burden the donor feels about being obligated to make a donation, the indebtedness the recipient may feel towards the donor. It should be noted that in the majority of the cases, organ donors view the experience positively, but it still important to consider the psychological aspect of donation.

To play devil's advocate for a moment though, I wonder why we impose a system of donation that requires that organs be a gift. I understand that potential for corruption, but the U.S. has a tradition of free markets, and there is a clear market here with a well-defined demand and supply. Of course, the market could not be completely 'free,' but it perhaps could be much less 'deregulated' than it is right. Currently, my understanding of the transplant system is that organs are listed on a list on the national registry (United Network for Organ Sharing, or UNOS). Potential recipients are ranked on a list; the ranking is based on various criteria that vary by organ. When a recipient is at the top of the list, they get the first shot at an organ. The donors are anonymous unless the recipient brings their own donor (such as a sibling). Now, imagine a similar system with anonymous donor-recipient pairings, but instead of giving a 'gift,' people are allowed to bid on organs. There are several benefits to this system, especially in light of the psychological issues discussed above. First, by offering compensation for organs, this could potentially expand the pool of potential donors, leading to more lives being saved. Second, by making the donation a transaction instead of a gift, it is possible that people would have less psychological hangups, and would view their donors as merely someone who they made a deal with, such as a car salesman, instead of their 'life savior.' Lastly, by putting a price on the organ, in theory, this would help curtail the black market for organs (okay, maybe not, but in theory, it would help).

The obvious problem here is that richer recipients will be better able to purchase an organ. However, perhaps this could be mitigated by utilizing the ranking system to weight dollars of people in greater need more highly. Still, I think most people would find the system unsavory, even if it were to lead to a net increase in organ donations. Perhaps a system utilizing a Dutch auction, or even one in which there is a fixed price for organs (such as the 'market' in place for the eggs of smart, young women with a college degree from an accredited institution) may increase the amount of donation.

In the end, I think the system in place, while less than ideal, is the best compromise between ideals and practicality. However, I think the notion of the market is interesting to consider because, depending on how science advances, we may one day have to ponder what the price of a synthetic organ should be.

Friday, December 28, 2007

I was recently discussing politics with a friend who is interested in health policy (and is also a med student). I realized that while I knew the general ideas that the candidates had, I wasn't too familiar with the specifics. I had tried previously to go to candidate websites, but I found myself getting bogged down, as each one had a different way of presenting their proposals. I asked my friend if there were any sites that simply compared the different policies. He directed me to health08.org, a website run the Kaiser Family Foundation. The site was easy to use, and let me compare any candidate's plan against any other candidate's plan.

As I tend to be liberal-leaning, I compared Senator Clinton's plan with Senator Obama's and Senator Edwards'. The comparison was fairly helpful, as it went through the plans and compared them on a point-by-point basis. Here's a summary of each plan, and my opinion of them:

Clinton: Every American is required to have coverage. To make this affordable, the plan will provide income-related tax subsidies. Plan options, both public and private, will be available through a "Health Choices Menu," which would be operated by the Federal Employee Health Benefits Program. Coverage through employers and public programs would continue. Employers of small businesses would receive a tax subsidy to offset their costs. Cost estimate: ~$100 billion, partly financed by rolling back tax cuts on those making over $250,000.

Obama: Every child will be required to have coverage. Employers will either have to extend benefits or contribute to a new public plan. A new "National Health Insurance Exchange" would facilitate enrollment in the new public plan. Employers would receive tax benefits to offset catastrophic costs. Cost estimate: ~$60 billion, partly financed by rolling back tax cuts on those making over $250,000.

Edwards: Every American is required to have coverage, with a goal of universal coverage by 2012. The plan would create nonprofit "Health Markets" in which public and private options would compete with each other. Expanded public funding for coverage of low income adults would also be provided for. There is no provision for employers. Cost estimate: ~$100 billion, partly financed by rolling back tax cuts on those making over $200,000.

So basically, the three candidates are providing the same healthcare plan with minor tweaks. I think Obama's would benefit from mandating coverage, but on the other hand, the plans with mandates do not technically guarantee coverage. Simply by saying you must be covered doesn't necessarily make it so. And what are we going to do if people choose not to buy? Fine them? Put them in jail? Maybe I am not understanding the mandate, but if they really want universal coverage, they should just expand the Medicare payroll tax deduction and call it the "National Healthcare" payroll deduction. Of course, that will never happen, but I'm jus' sayin'... Anyway, given what I've read, I think Clinton's and Edwards' plans sounds the best and have more detail. Obama's is good, but not as broad as theirs; however, his plan might be the one that is most realistically implementable. It is interesting to see his views on policy. I think Obama would be in support of mandates if crafting a system from scratch, but in this climate, perhaps he believes that a more incremental change is more feasible. I suppose I should admit a bias towards Obama, but I think any one of the candidates I mentioned above would be more than competent.

To be fair, here is what I understand of some of the other candidates' plans (in no particular order):

Giuliani: Healthcare reform 9/11. Now.

Paul: Ban healthcare as it was not mentioned in the Constitution.

Huckabee: Plan members will ask themselves, "What would Jesus do to heal himself?" instead of making claims.

Kucinich: Mars has healthcare for all, so why can't we? I was the first to propose the Martian plan.

Monday, December 24, 2007

Quick site update: I installed Photoshop this past week and started playing around with it. Heh, probably not the best software for the colorblind. Anyway, check out the new logo up top!

When I was on Family Medicine, my preceptor was involved with clearing people medically before they could fly. Usually it was fairly routine, but the one thing that differed from the typical physical is that he had to scrutinize their eyesight much much more than usual. One of the items he had to check was their color vision and make sure they were not colorblind.

There are several ways to do this, but the most popular method involves the Ishihara Color Test. We have all seen these before. They are basically dots of different sizes and colors that form a number that is visible only to people who are not colorblind. Here is an example (do you see a number below?):

Can you see the '74' in the middle in green dots? If not, that might mean you're colorblind (or illiterate, I suppose). The reason the dots are red and green is that this is the most common form of colorblindness with up to 10% of males having this disability. I mention 'males' because the gene for the red and green receptors are on the X chromosome, which means the inheritance is X-linked. There other forms of colorblindness like blue-yellow colorblindness, but this has autosomal inheritance and is less common.

However, even after one has diagnosed a patient, it is interesting to consider how they see the world. A colorblind person went ahead and tried to demonstrate through photographs, which I found interesting. I wonder though, when making the page, didn't the images look identical to him since he couldn't actually see the full color images like most of us can? How does he know he did it right? I guess there really no way to see the world exactly as he does, but it's still an intriguing approximation.

Friday, December 21, 2007

I recently read an article on the recently released Awake: The Movie. As the movie's IMDB profile notes, "The story focuses on a man who suffers "anesthetic awareness" and finds himself awake and aware, but paralyzed, during heart surgery. His young wife must wrestle with her own demons as a drama unfolds around them." Yawn. The only thing this movie has going for it is Jessica Alba. Heh, I just used that as an excuse to find that gallery. At any rate, the movie has some anesthesiologists concerned due to its portrayal of unscrupulous anesthesiologists torturing a patient and planning his murder during a procedure in which he has already been sedated but is still aware.

I have not seen this movie, nor do I plan to. The trailer I saw just sounded ridiculous. I sure hope no one out there is dumb enough to believe that this is commonplace. If so, that person probably also believes in The Force, hobbits, and the Matrix. How do movies like this even get made? Do they just draw ideas out of a hat? I remember when I was younger, people would always tell me to be "creative" by coming up with an idea, putting it in a bubble and then drawing lines to other bubbles and seeing what I came up with. At least, I think that was the idea. I imagine the bubble system here went something like:

Wednesday, December 19, 2007

I recently read an interesting article in the New York Times Magazine entitled Dr. Drug Rep. In it, a psychiatrist Dr. Daniel Carlat describes his experiences as a drug representative for Effexor XR over a year. He describes how he was initially recruited by Wyeth Pharmaceuticals, the producers of Effexor and his feelings about his first trip out as a drug rep. He describes the tactics the drug reps used to convince him to represent their drug, and what points they trained him to use to convince others. Dr Carlat's perspective is intriguing because he seems to be truly a man in the middle, as he neither a paid employee of a pharmaceutical company, nor a shrill PharmFree representative, touting a supposed moral high ground.

As medical students, we are secondary or tertiary targets for most reps (after physicians and residents). We stealthily sneak in to lunches, or are at times openly invited. We eat, casually listen, and sometimes come away with a pen. The reps vary: some ignore us, some politely greet us, and a few even try to make us converts early on. In any case, most medical students find the whole thing a bit comical but mostly harmless.

However, for those of us with a few ethical concerns, I have broken the issue down into point/counterpoints:

Point: Even though we are not the direct targets of the reps, we are still influenced by their pitches. Students will remember those drugs that are described more easily later on when they become practitioners. While we might not think we are being influenced, prescribing practices tend to show the contrary on average. Physicians are more likely to prescribe drugs that are detailed to them than drugs that are not. And the reps know this: Pharma links up drug sales info from local pharmacies to DEA numbers on lists sold to them by the AMA. As the article notes:

The American Medical Association is also a key player in prescription data-mining. Pharmacies typically will not release doctors’ names to the data-mining companies, but they will release their Drug Enforcement Agency numbers. The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money.

Also, given the time constraints of such interactions, physicians are more likely to trust the nice-looking pharm rep who brought lunch instead of thoroughly investigating whether or not a particular drug is efficacious.Counterpoint: Free food

Point: At the end of the day, it is the patients who suffer when they are asked to purchase overpriced or inappropriate medications. As physicians, we have a fiduciary responsibility towards our patients to act in our patients' best interests. They trust us to do so, and their lives depend on it, quite literally in some cases. If we prescribe medications with competing interests at play, we do our patients a disservice.Counterpoint: Free pens, or even a laser pointer (Thank you, random dialysis dude)

Point: If one were to become involved as a representative for a drug, either by doing lunches or giving lectures, it is easy to lose one's objectivity in light of the significant additional income as well as prestige such events offer. Even by merely receiving gifts, there is some compromise of our integrity due to the norms of reciprocity deeply ingrained in our culture.Counterpoint: FREE STUFF!!!

Okay, in all honesty, I am still divided on this issue myself. I agree that the free stuff is effective (if it wasn't, why would Pharma spend so much money/time doing it?) and I agree that I most likely will be influenced. However, my economic senses chasten at the thought of limiting the marketing potential of a firm in a capitalist society. We allow gas companies, and car companies, and even alcohol companies to market their products in almost any manner possible. Why are drugs held to a different standard? All the other products I mentioned can also seriously harm individuals. Of course, those products do not involve a "fiduciary agent" like a physician who restricts their purchase, but still, why should that matter for marketing efforts? There seems to be inconsistency here, as we clearly trust physicians to prescribe drugs, yet are wary of how they may be swayed by representatives of the pharmaceutical industry.

To me, it seems like the current system cannot hold. I see one of two solutions. First, either physicians should get serious about this issue. To do so, they should petition the AMA to ban the sale of DEA information to pharmaceutical companies as well as ban detailing as a practice, ie ban pharm reps from entering their offices (as some physicians have done). However, this seems highly unlikely due to the entrenched interests who would have no reason to undergo such a radical change. My other thought would be to have all physicians basically make disclaimers to their patients about which representatives for which drugs have been in their office in the past 3-6 months, much like researchers must make disclaimers at the end of journal articles. By doing so, physicians would be free to decide whether or not to accept reps into their office, pharma companies could continue detailing, but I think the main difference would be that the "consumer" patient would be better informed about how their physician practices medicine and how their physician's prescription choice is or is not being influenced.

Just my two cents. Any comments one way or the other would be appreciated.

Heh, I can't imagine how a couple with 'penis captivus' would even make it to the ER, and once there, what would they do? I guess you could locally inject some kind of muscle relaxant like succinylcholine or something.

Monday, December 17, 2007

Often times in medical school, we are taught the algorithms for patient care. However, due to the volume of information, less care is taken to make sure students understand what exactly they are ordering when they work up a patient. Diagnostic imaging can be a particularly confusing area.

Historically, X-rays were the first mode of imaging and have been the primary mode for the past 100 years of medicine. A more recent development has been computed tomography, or CT. The CT basically takes a series of x-rays and integrates the data to create a more detailed image. X-rays and CTs effectively work on the same principle, which will be discussed in more depth in another post.

Magnetic Resonance Imaging (MRI) is a relatively new form of imaging. Although MRIs are becoming increasingly popular, their cost makes them prohibitive for broad use, so far. Some common questions med students might have when introduced to MRIs are: what is an MRI? How does it work? What is the difference between a T1 image? T2? FLAIR? As a med student, I claim no expertise in this area, but here is what I have learned.

...eh, on second thought, why reinvent the wheel? I can't do as good a job as some of the following sites:

Sunday, December 16, 2007

So, the title is a bit misleading. I did not scour through multiple peer-reviewed journals to find the best of what's new out there, but I did enjoy The New York Times Magazine's end of the year issue, which is focused on the great new ideas of 2007. Among them are many new discoveries and innovations within science and medicine. They are all short pieces, 2-3 paragraphs long, but they do a decent job summarizing what's new out there. Here are a few I found particularly intriguing:

Sunday, December 09, 2007

I've recently noticed that The New Yorker has excellent and engaging science and medicine articles. Of note are three recent pieces about Asperger's syndrome/autism, retroviruses, and preventing nosocomial infections.

In Parallel Play, the author discusses his lifelong struggle with Asperger's Syndrome. Of course, as a child, he did not know he had such a diagnosis, and so he went through life merely with a sense that he was different. It is interesting to see the prism through which he constructed his world in his own words. Often, as students and doctors, we only see a patient's symptoms, but rarely are we able to experience and understand the world exactly as they do.

In Darwin's Surprise, the author explores the role that retroviruses have played in human evolution. In fact, some scientists have been able to go back through the human genome and not find fragments of old viruses, but also recreate them! (Think Jurassic Park, but on a micro scale). These paleovirologists argue that the inclusion of these viruses into our DNA can provide protective benefits against such disease like AIDS. One thing I didn't know prior to reading this is that apparently some scientists argue that humans developed placentas and live birth (vs eggs) as a response to these retroviruses. Something to ponder...

In an article entitled The Checklist (which eventually forms the basis for the book titled The Checklist), Atul Gawande argues for the use of a simple checklist in order to save lives. He describes how the complexity of modern medicine has gone beyond even the most organized specialists and experts. However, by using something as simple as a checklist, medical care improved greatly in several hospitals and the number of line infections decreased dramatically. Written in Gawande's usual style, the article highlights the need for physicians to pay more attention to how exactly medicine is delivered, even if it takes away from the so-called 'art' of medicine.

While all the articles are somewhat lengthy, I think they're all good reads. Check out The New Yorker if you have a few minutes to spare.

Tuesday, December 04, 2007

War, huh, yeahWhat is it good forAbsolutely nothingUh-huhWar, huh, yeahWhat is it good forAbsolutely nothingSay it again, y'all-Edwin Starr, War

Until recently, one could probably say the same about the appendix. But, that's all the appendix wants: respek', yo. Well, now perhaps it can. This New York Times article explains one idea about an evolutionary role for the appendix, specifically, that the appendix serves to 'reboot' the gut if other flora are wiped out by diarrhea or dysentry. But, what if the appendix houses something like C. difficile? (Quick! How does one diagnose C. diff diarrhea? How does one treat it?)

Even if this idea stands the test of time, the appendix faces an uphill battle. Think about its name: the appendix. Something that's added on, tacked on the end, easily removed without affecting the main work (Q! What's the most common etiology of appendicitis?). Poor lil appendix. Even some cancers that start in the appendix don't get no 'respek' til they spread to the liver (Q! Name the cancer and some common symptoms).

Alright, I think I've stretched that out far enough... heh, and in the end, the appendix, what is it good for? Still pretty much nothing. Now, to start a (hopefully) new feature on the blog, here is Check It Out, where I link to something interesting I either found or have been reading about recently.Check It Out: Radiology Picture of the Day

My family medicine review book notes that some patient might refuse "sigmoidoscopy because they find it distasteful." I think they should find another gastroenterologist, because if their sense of taste is any way involved with their sigmoidoscopy, something's not right.

Same review book: "Physiologic fatigue is common in mothers of newborns, individuals who do shift work, athletes who overtrain, and in third-year medical students."

"We got an issue in America. Too many good docs are gettin out of business. Too many OB/GYNs are unable to practice their love with women all across this country." -President George W. Bush

From First Aid for Step 1: "Horner's syndrome clinically presents as Ptosis, Anhidrosis, and Miosis. Mnemonic: PAM is horny."

A joke I heard from a friend: An internist, psychiatrist, surgeon, and pathologist go duck hunting. They go out into the blind and wait for a duck. The internist is up first and sees a bird fly over. He looks out and says, "I think it's a duck... but it could be a quail, or pheasant, or dove, or maybe..." and the duck flies away. The pyschiatrist is up next. She sees a bird fly over and thinks, "There's a duck! But... does it know it's a duck? Is it self-actualized as a duck?" and the bird flies away. The surgeon is up next. He sees a bird fly over, and *BOOM* goes his gun. He then says, "Pathologist, go over there and tell me if it's a duck."

Monday, December 03, 2007

So, here's a little story I heard from a friend that I found both interesting and educational. I cannot vouch for its veracity, but like Stephen Colbert, my gut says it's true.

Back in 18th century France, French mothers were very concerned about who their daughters consorted with. In order to save them from men of suspect character who may be intent upon sowing their wild oats, the mothers would warn their daughters to avoid men with bobbing heads. The question for modern day medical students is, why?

The answer? The bobbing head, also known as De Musset's sign, is a sign of severe aortic regurgitation caused by syphilitic aortitis. Had the daughters flaunted their mother's warnings and flirted with these loathsome Lotharios and perhaps gone in for the proverbial French kiss, they may have also noted a bobbing uvula, also known as Muller's sign.

The only question I have is, why did French mothers know about syphilis? Hmm...

Saturday, November 24, 2007

Sorry for the long delay in posts (not that anyone reads this regularly). For the past month, my DSL connection has been down, and I am about ready to throttle someone at an unnamed "new" company (*cough* ATT *cough*).

Anyway, I am now starting my third month of three of my Internal Medicine rotation. I'll have more to say about it in future posts, but here is a video that our chief resident last month was quite fond of, to the degree that he tried showing it during Morning Report:

Monday, October 22, 2007

I should preface this post by noting that my experiences are shaded by working at a public hospital that does not yet have electronic medical records. I am not complaining about my workload in particular, but rather the structure in which everyone in the health care field operates in when 'rounding' on patients in the hospital.

A Typical Morning

On many services, mornings are scheduled around some kind of morning conference. For this example, I will assume that I am on internal medicine, Morning Report is at 8:30 AM, and I have three patients to see. The attending wants to round after Morning Report at 9:30. This all sounds reasonable enough, right? However, here is what really happens. The residents, reasonably enough, want to discuss the patients prior to attending rounds, so we have prerounds/work rounds, typically at 7:30 AM, before morning report. I allocate about 30 minutes per patient (15 minutes for looking up results from the previous night, 10 min to see the patient, and 5 min transit time), so this forces me to arrive at 6 AM to see my 3 patients prior to work rounds.

Now, if I were able to utilize that time fully to understand everything that had happened with my patient the previous night and discuss problems thoroughly with my team, that would be great. But no. Instead, I waste most of that 1.5 hours hunting down charts that are being shared by up to 10 individuals who are caring for the patient (nurses, respiratory techs, other techs, consult teams, etc). When I finally find the chart, I have to hunt all over the place for vitals, medications, etc, which may or may not be filed under the correct tabs. Then, I have to read notes other people have left, but there are two problems here. First, everyone is forced to regurgitate the same basic info about the patient, so you have to skim through all of it just to get to the relevant stuff. Second, HANDWRITING: some people just refuse to write legible notes, thereby defeating the purpose of leaving a note. In that 90 minutes, I sadly only get 30 minutes max to actually see how my patients are doing, let alone think and discuss the issues they have.

Why 'Rounds'?

Why do medical students round? There are many ways to teach and practice medicine. There is no inherent need to 'round' in order to care for patients. My history may be a little bit rough, but I believe the idea of rounding in American medical education can be attributed to Sir William Osler and the program he began at Johns Hopkins. Physicians had rounded prior to that, but my understanding was that Osler was the first to integrate medical students and education into this system. And, for decades, the system succeeded and many learned medicine at the bedside. And, I must admit, I learn a fair amount on rounds. However, it is ironic that while the buzz in medicine is all about 21st century technologies and practices, we are still stuck in a 19th century work flow pattern. Remember, when Osler rounded, there were no X-rays to interpret, no EKGs, no other fancy studies. Heck, they barely had blood pressure cuffs. Rounding was an appropriate way to pattern work for the 19th century hospital, but rounds are no match for the information overload that each patient now presents.

A Modest Proposal

Well, perhaps several mini-proposals. Rounds should change to keep up with the advances in medicine. First, there is no excuse for having paper charts in the year 2007. It just makes no sense when nearly all the data that goes into charts is generated by some piece of electronics. Second, why must I see my patient 3 times each morning, yet not really examine them because each time I am in a rush to get to the next set of rounds and/or conference? The med student pre-pre-rounds and pre-rounds should be combined. The obvious criticism is that the med student would not be as exposed to the data and would not be required to think on their own. This is easily avoided by simply ensuring that the residents allow the medical students to examine the patients first and to "lead" the rounds for their own patients. By doing so, the students will have more opportunities to ask questions and have their physical exams directly observed by their interns and residents who can help them do a better job. Lastly, and maybe this is just because I'm not a morning person, can't we just combine Morning Report with noon conference? The "break" at 8:30 seems nice, but all it is really doing is extending the day in a particularly inefficient way by breaking everyone's work flow. Anyway, that's my two cents.

Monday, October 08, 2007

While I am no expert on the patient-doctor relationship, it seems to me that many patients would benefit from a simple introductory handout that explained to them the nature of the patient-doctor relationship and what their rights and responsibilities are. Based on my experiences, here are ten tips (in particular order) for patients to help them get the most out of an office or hospital visit:

1. Bring Your Meds - It is simple really. You are in pain, you come to see the doctor, they prescribe you medication to relieve your pain. When you come back the next time to see the good doc, the least you could do is bring those medications (or some record of them) along. Why? There are several reasons. First, doctors do not always remember what they prescribed, and the records are not always accurate. The best record is what you are actually taking. Second, if you are seeing multiple doctors who prescribe you different medications, it is important for each doc to know every med that you are on. Third, by bringing the actual meds in, the doctor is better able to gauge how much you are actually taking and prescribe you an appropriate dose / # of tablets.

How to achieve this? Again, it is very simple: put all of your medications in some kind of bag at home. When it is time to see the doctor, bring this bag along with you. That's it. That is all you have to do - you don't have to memorize names or doses of meds. Just bring 'em along.

2. Ask for reports - Any time a doctor runs a test on you (X-ray, CT scan, sends a sample to pathology), they get a report back with the results. Ask for copies of these results! It's your health, and your test, that you likely paid for. You might as well know the outcome, right?

3. Bring your reports - See #1 and 2 above. This applies if you ever see a new doctor.

4. Wear underwear - This applies more to the hospitalized patients. If you are conscious, in no acute distress, and have no problems directly in your groin area, feel free to keep your tighty whites on. No, really, we insist. Okay, so I know as physicians, it is important to fully examine the patient and this is important on day 1. However, on Day 5 for a patient with chest pain, I am not really concerned with their scrotum. While 'going commando' is always a bit of a thrill, you should not do so because... uh... umm... you'll get scrotal cellulitis. Yea, uh, that's it.

5. Go home - Again, this is more for the ambulatory hospital patients. If you are not acutely in pain and you are just waiting for a test that is of little diagnostic value, you can leave. As my upper level resident pointed out today when I asked him why we did not restrain an agitated patient who was trying to pull his IV, hospitals are not jails. As a patient, you have the right to leave. To do so, you must sign a form that says you are leaving "against medical advice" or AMA. Of course, this sounds ominous, but in some cases, it is actually to the patient's benefit to leave AMA. Why? Well, in some cases, physicians practice CYA (cover your ass) medicine in which they order a bunch of pointless tests that take forever to come back. During this time, the patient is just sitting there, waiting to catch something from the hundreds of sick people around them. If you are feeling well, and the tests can be done as an outpatient, well.... go home!

6. Ask questions -Pretty self-explanatory. If you don't ask questions, you'll never know. At the very minimum, you should know the name of your diagnosis, and what it means, and what the doctor is doing to treat your condition. Write the diagnosis down, and then later, look it up online. Educate yourself using trusted websites online (WebMD, MedlinePlus, etc). Do NOT bug your doctor with every crazy 'miracle cure' you read about online though.

7. Learn English - Sorry, that may be a little harsh, but the more you know (of English), the more you'll know about your disease, and the healthier you'll be. Sigh, I realize, I am writing this in English so if you don't know it, this will be lost on you, but still, gotta say it.

8. A "medication" is anything that you put in your mouth that is not food/water - Just because you got it from a nutrition store does not meant it cannot affect your body like something you got from the pharmacy.

9. Short, simple answers - The more extraneous things you say, the less doctors hear. The doctor is like Sherlock Holmes, and they are trying to figure out why are you in pain. When answering their q's, try to focus on the basics like: what, when, where, why, how (the "who" is hopefully you). Like Joe Friday would say, "Just the facts, ma'am."

10. Smile! - Doctors tend to be tired and grouchy sometimes. However, it is hard for us to be mad at a happy patient. If you smile, your doctor is likely to smile back. In fact, anyone would: it's simple psychology. Doctors are visibly nicer if the patient seems nice. This is not ideal, but it is true. You should see some of these disillusioned residents when they encounter a pleasantly demented 85 year old grandmother...

Friday, September 21, 2007

Why am I writing about Dr. Dubin again? Well, two reasons: he seems to be the reason a majority of you end up at this blog, and frankly, I became curious as to what the rest of his story was. Where did he go to med school? What was his practice like? Why did he write a book on EKGs when he was a plastic surgeon?

Today, we find out the whole story... or what I could lazily dig up with a few google searches. Here's what I found:

From a 1987 UPI release, referenced here and reproduced below, Dr. Dubin was a millionaire plastic surgeon who became addicted to cocaine and pornography. He also apparently upset his nudist neighbors in Florida:

Dale Dubin Sentenced To Five Years Proprietary to the United Press International 1987 March 7, 1987

A federal judge sentenced millionaire plastic surgeon Dale B. Dubin to five years in prison for what the judge called an obsession with pornography and cocaine that turned the doctor's life into a tragedy.U.S. District Judge William J. Castagna told Dubin at a sentencing hearing Friday he could not see how a ''person of your talent, ability, education and interest in art,'' could have turned his life into such a ''tragedy and waste of such a rare and needed talent.''Dubin pleaded guilty six weeks ago to 22 counts of child pornography and cocaine charges.Eleven of the drug counts involved a 16-year-old girl who was seduced by Dubin with the help of pills and vodka and eventually agreed to participate in sexual encounters with Dubin, another 17-year-old girl and a 23-year-old woman.Dubin videotaped some of the encounters for his pleasure. The incidents took place at two of his condominiums and the Pasco County nudist resort of Paradise Lake.He is expected to serve his time in a minimum security facility where he will be able to receive drug counseling. U.S. Attorney Robert W. Merkle, who prosecuted the case, told Castagna that no crimes ''are more violent than the use of child pornography and the distribution of narcotics.'' He said Dubin's attempt to minimize his activities as just a ''lifestyle'' was a ''new low in euphemisms.''Merkle said it was particularly aggravating that Dubin used his medical knowledge to satisfy his own appetite and risk the lives and mental health of his victims.Dubin, 47, stood with his head bowed throughout the 40-minute hearing Friday. Except for a few mumbled words about a letter to the judge, he did not say anything.In that letter, Dubin complained of the ''lurid display'' of his case by prosecutors and claimed details of his activities were ''egregiously distorted'' by the press. He also spoke of his sexual escapades as examples of ''an occasional clandestine soiree.''Dubin was arrested Aug. 11 at the mansion in Lutz, Fla. he called Hassle Free, after being sucked into a child pornography sting by sending off a $100 bill to buy films including ''Barbarian Girls.''The Dubin story received extensive news coverage as his doctors unsuccessfully tried to have him committed to a mental hospital for treatment of what they called potentially suicidal depression, and Merkle countered by adding details of the case into the court record.

The post gives some details, but not really much else to go on. Another post on Medstudentitis (well, a comment) notes that Dubin's license to practice medicine in Florida has been revoked.

The only other thing I could find was a post on a Dale B. Dubin from Fort Myers, FL who is apparently an avid hibiscus grower. The linked picture is below.

The site never links this Dubin to the one from the EKG book, but... c'mon, we all know it's him. At any rate, I still have no idea where he went to med school, what his practice was like, or why a plastic surgeon was writing a book on EKGs. The mystery continues...

If you're interested in the book (which is actually quite good), check out:

Wednesday, September 05, 2007

"Aphasia" is the loss of the ability to produce or comprehend language. The first day of med school is typically a period of aphasia for the young Medi. He or she enters a world in which obscure terms become common parlance, and the terms flow freely from the mouths of experienced practitioners. This lack of knowledge, this pseudo-aphasia, is of course a necessary part of the learning process, but learning to speak in medicine is unlike learning any other language in the world.

One of the most challenging aspects of learning medicine is learning how to speak the language. Although I have learned to speak in many abstract languages over the years (English, Spanish, Hindi, programming languages, social languages), learning "medicalese" has proved to be quite daunting. The breadth of the vocabulary nearly matches a modern spoken language. The time in which one has to learn the language is brief, relative to other languages. The words are complex and not always easily related. The presence of multiple synonyms and eponyms (using a person's name to describe a disease) complicates the picture. Yet, somehow, after a few years, we as students slowly begin to make sense of the terminology and begin to take ownership of the medical words we produce.

However, one soon comes to see that learning the language to the point of comprehending it is only the first step of the challenge. Even the challenge of producing the terminology is eventually conquered. Yet, just as the medical student feels comfortable conversing with colleagues and peers, the student realizes where the true challenge lies in communicating medical ideas: the patient.

Today, I saw a patient in clinic. The Hispanic woman had a history of seizures for which she had recently had a brain scan. She spoke only Spanish, but her Spanish flowed easily as she described her situation. My Spanish is the kind one receives after 6 years of classroom education. I could generally follow her, but my mind had to stay ever alert, lest I get confused on a word that was not in my limited vocabulary.

One of her questions during the visit was whether she would find out the results of the scan. I had read the results prior to calling her into the room. The MRI of her cerebrum showed medial temporal sclerosis among other findings, which we believed was potentially due to head trauma in her childhood and a cause of her seizures. Had she spoken English, I feel my instinct would have been to read her the report. However, the additional language barrier gave me pause. I sheepishly told her that I would discuss with my attending and return with the results.

My attending also only spoke English. Even if we had both been fluent in Spanish, I suspect we would have had a difficult time explaining the lesion to this patient. I could have called a Spanish interpreter, but what would I have told him to tell her? While I might be capable of spouting out "temporal lobe abnormality" and "gliosis," how could I convey what this meant in plain terms to the patient? Still, something had to be said. After returning to the room with my attending, I showed the patient her MRI on the computer screen and had the attending describe it in English, while I tried my best to explain in Spanish. After doing so, the look on the patient's answered the question I was about to ask: "Entiende Usted lo que estamos diciendo?" (Do you understand what we are saying?). Her chagrined "No" probably embarrassed me as much as it did her. I attempted again, and this time she acceded to understanding. Yet, I fear, she understood only to the level that there was a problem in her brain, but I failed to convey the more complex picture that actually existed.

Why is this so? Of course, medical training creates an educational gap between physician and patient. But, this does not explain the entire situation. Medicine seems to cling to its roots as a descriptive field. In fact, the use of eponyms can be viewed almost as an act of hubris, of ownership, a researcher securing his place in eternity by attaching his or her name to the afflictions of his or her patients. Fortunately, medicine has trended away from the use of such eponyms, but they still litter the landscape. Another issue is the multiplicity of names for the same disease. While this may reflect the evolution of understanding over time, or independent discoveries, it seems that we as a field revel in being able to spout off the 5 names for a syndrome. We use language as a measure of skill and competency of our peers and colleagues. We also use language as a shield, protecting us from the inquiries of our patients, obscuring the knowledge we have attained.

The sad part is that often our shield appears as a weapon to our patients. Our patients enter the foreign land of the hospital and are bombarded by the foreign tongue of medicalese. We have now transferred our medical student aphasia to our patients, who are able to neither produce nor comprehend this "medicalese" we speak. When they ask for clarification, we often either intentionally use technical language to describe the situation so that we do not waste time by truly clarifying what is going on. Or, we are so caught up in presenting all our medical knowledge, that our eyes turn inward, reading what is kept in our memories, instead of looking outwards, and seeing the confusion and eventual submission. The patient learns to simply accept what we tell them instead of truly understanding their condition. However, without true understanding, the patient can never fully take charge and ownership over their condition. One can only hope that as we move forward as medical students, we shall remember to listen to ourselves speak as our patients do, and learn to use our language not as a weapon but as a light to enlighten the patient and enrich their lives.

Saturday, August 25, 2007

Writing notes is one of the basic activities that medical students, residents, and physicians perform. Whether it is a detailed pediatric SOAP note or a brief surgery SOAP note, this is how we communicate with each other, now and for future reference. Someone may need to read your note months or even years from now, so you want to make sure your note is written well.

O - Objective: any data, whether in the form of a physical finding during your exam, or lab resultsA - Assessment: diagnoses derived from the history and objective dataP - Plan: what you intend to do about the diagnoses from your assessment

Pretty simple, right? However, Day 1 on your first rotation comes around, and you're asked to write a note. You write down "SOAP" but... then what?

Well, if it is the first time you are seeing a patient, you should write a full history and physical (H&P). The H&P should include the history of present illness, past medical history, past surgical history, allergies to meds, current meds, relevant family history (e.g. "Mother and Sister had breast cancer"), and social history (tobacco history in pack years, alcohol, drugs, etc). For HPI, a helpful mnemonic is OLD CHARTS:

O - Onset: when the problem began

L - Location: what area of the body is affectedD - Duration: how long has it been hurting, is the pain continuous or intermittent

T - Temporal: is there any pattern to the pain, such as always after meals

S - Associated Symptoms

It is also a good idea to ask about previous episodes of a similar pain, or any relevant family history.

Anyway, back to the SOAP note. Assuming you are familiar with the patient, the SOAP note details what has occurred since you last saw them, typically the previous day. You want to note any changes in their condition or treatment. If nothing has changed, you can write "Did well ON (overnight). Tolerating food and medications. NAD (no acute distress)" or something along those lines. The objective portion should be their latest vital signs, as well as their "ins & outs" such as IV fluids, UOP (urine output), BMs (bowel movements). The objective portion also includes any new lab or study results. The assessment is generally a restatement of what the patient's ongoing diagnosis has been (e.g. "This is a 37 year old female, POD (post-op day)# 3 after a lap chole (laparascopic cholecystectomy)"). The plan describes what you want to do for the patient next. In the hospital, it's a good idea to run through all the major systems in your head and try to think about what is going on for each one. Here is a simple list: Airway/Breathing, CNS, CV, Endocrine, Fluids, Heme, ID, Renal (UOP), Social. Depending on the rotation you are on, other systems may be more relevant. If nothing comes to mind for a system, there is usually no need to mention it unless your residents or attending specifically want you to.

That's pretty much it. After writing several of these notes, and seeing the other notes in a patient's chart, one starts to develop their own style of writing them, so don't be too concerned about sticking to one particular format as long as you find one that suites how you think while covering all the pertinent information.

For more basic information on how to ask certain histories or perform focused parts of the physical exam, I recommend Bates Guide to Physical Examination:

The book has good illustrations and simple explanations of why doctors perform certain exams. The version above is pocket-sized, which is handy for carrying around in your whitecoat. However, if you are looking for detailed information about the physiology behind certain parts of the physical exam, a physiology textbook reference may be more useful. Still, Bates is the standard for learning how to do a history and physical. Many of my attendings still have the book on their reference shelves from back when they were in medical school!

Thursday, August 16, 2007

As you might recall, this blog has previously investigated the background into the mysterious Dr. Dale Dubin. However, as mentioned last time, regardless of Dr. Dubin's extracurricular activities, the book "Rapid Interpretation of EKG's" is a good introduction to how to read EKGs. However, as one peruses the book, other interesting findings come to light. Take a look at a page from the 2nd edition, reproduced below:

There are but two interpretations of this post:

1. Dale Dubin is using the stereotype of African Americans having "rhythm" to emphasize a trivial point about the cardiac rhythm.... racist!

OR

2. Everyone has a tiny black man that lives inside their heart. This tiny black man (I'll call him "Mr. Biggs") is very musical. Mr. Biggs loves to play on his drums, and by doing so, he keeps our heart ticking, kiddos. Thank you, Mr. Biggs. You are a true hero.

I don't know about you, but I believe #2 is the proper interpretation. I think the interpretation you choose to believe in says a lot about you. Which one seems right to you?

The New York Times has an article about Google and Microsoft and their approaches to healthcare. After reading that, I decided to read a Google Blog entry about their product managers' thoughts on healthcare. It seems that both large firms see a big opportunity here, especially Google. I must admit, I am biased towards Google based on having used their products and what I have read about their corporate culture. However, while generally a proponent of such technology, I wonder how serious privacy issues are in this arena.

Perhaps this is obvious, but I think applying IT to healthcare should be a national priority for a plethora of reasons. As a med student, I am trained to take a fairly routine history, which includes history of present illness, past medical/surgical history, drug allergies, current medications, family history, and social history. A lot of this information is constant over time and occasionally can be crucial for the patient's care. However, patients are not the best historians. They forget the names of their meds, they forget surgeries they've had, they forget even why they came in sometimes!

A health record that is owned by the patient can help remedy this. Imagine an international standard for a health record. I'll call it a "Portable Health Record" or PHR, for short. In digital format, your .phr file would contain all of this information in a standardized format. Viewers would help you easily access and understand the information, which you could update as necessary. The same would go for the physicians whom you would give access to. By having one standard format, if you ever move or switch physicians, your health record would stay intact, and your new physician would be familiar with how the information was stored. Simple, right?

However, privacy is a major issue that shatters this simple view. People would worry about insurance companies or others who may not have your best interests getting their hands on this information. Such information could be used to exclude patients from healthcare plans, or to target them for direct marketing. One can imagine even worse possibilities.

But, how realistic is this? I believe that with proper safeguards, such as data encryption and appropriate permissions systems, this risk is really just a straw man. We are already exposed in many ways, by using online banking and credit cards. While there are real risks involved with those activities, millions of such transactions occur everyday. As the Google article alludes to, if we can use IT to reduce medical error, I think from society's point of view, this benefit outweighs the risk/cost of exposing some to an invasion of privacy. Perhaps I feel that way since I have no personal experience with identity theft, but I think if people are responsible and the technology is developed appropriately, it will benefit patients, physicians, and society.

Monday, August 13, 2007

Many students are puzzled about how to interpret EKGs. They are often directed to "Rapid Interpretation of EKG's" by Dale Dubin, a supposedly classic introductory text on how to read EKGs. The book's tone is conversational, and one quickly comes to realize that Dr. Dubin believes he is God's gift to reading EKGs, as evidenced by his:

thanking himself in his acknowledgements (ok, fine, maybe it was his father who had the same name, but there's no way to distinguish this in the text)

using his own quote as an introductory quote for the book, but referring to himself as "DD" to make it seem more mysterious

just his overall tone

offering a car to anyone who read the copyright notice in one of the editions and mailed in.

That last one sounds too good to be true, right? And all this makes you wonder, who exactly is Dale Dubin? Well, according to this article on snopes.com:

"But sometimes lore manages to intersect with real life when a legend
long extant is duplicated in actuality. (Folklorists term this
phenomenon "ostension.") In 2001, Jeffrey Seiden, a third-year medical
student at Yale University, was studying his electrocardiography
textbook when he happened upon the following message tucked away in the
book's copyright notice:

Congratulations for your perseverance. You may win the car on page 46 bywriting down your name and address and submitting it to the publisher.

Dr. Dale Dubin had inserted the note into his 50th printing of his
"Rapid Interpretation of EKGs," putting his classic Thunderbird up for
grabs. Of the 60,000 who last year bought the book containing the offer,
only five spotted the hidden message and contacted the publisher with
news of their find. The five names were placed in a hat, and Jeffrey
Seiden's was chosen at random. The 1965 Thunderbird convertible was
delivered to him on 4 December 2001 by Dubin's daughter, who drove it to
Seiden's school."

Nice story, right? But guess what:

Yale officials heard of the contest only at the last minute, but they
allowed the award to be made on campus and helped with some of the
publicity. Since then, however, Yale has done what it can to distance
itself from the affair. When questioned about the award, Karen Peart, a
university spokeswoman, told the /Hartford Courant/: "This is not a Yale
matter."

The school's reluctance to be associated with Dubin stems from
revelations about his past: Dubin is an ex-convict whose medical license
was revoked after a 1986 conviction in Florida on federal drug and child
pornography charges. He was sentenced to five years in a federal prison
and was released in 1989 after having served 3½ years.

Thursday, August 09, 2007

As a med student, and one who had recently completed his surgery rotation, I feel I had a relatively unique perspective while reading this book, as compared to most readers. It was also interesting to read this book and gauge my reactions, relative to how I reacted when reading Gawande's prior book Complications. When I read Gawande's first book, I had not yet started medical school, and had at best, an educated lay person's background. I found the stories there intriguing and confirmed my romantic notions of medicine. This book mirrors my own internal evolution to a certain degree. Less romanticized, more practical, it discusses more of the everyday issues in medicine, ones that I see often as a student out on the wards. People do not wash hands as much as they should, the science of efficiency has not been applied to medicine, and the book takes us all to account for that. While medical technology has become remarkably efficient and high-tech, the actual delivery of medicine leaves much to be desired. Anyway, I digress.

The book reads very much like Complications. Gawande presents 12 separate essays about different aspects of healthcare, from the advances in obstetrics to the lack of investment in studying the provision of care to the doctors who are involved with executing prisoners who have been given the death penalty. Unlike Complications though, Gawande injects more of his own personal opinions after a more dispassionate presentation of each subject. The writing is sparse and clear, making it easy to read. Some of the chapters read almost like a medical Profiles in Courage

However, unlike Complications, this book did not leave me feeling as enthralled. Perhaps I have become jaded by medicine, or perhaps the topics of 'improving' medicine are simply not exciting. I think I liked Complications better simply because it dealt with more esoteric issues. While I agree with Gawande that the topics covered in Better are more important and can potentially affect many more people, the cases covered in Complications are simply more intriguing, such as the woman with necrotizing fascitis, or the reporter who sweat too much.

Overall: 9 out of 10 - a good engaging read that covers many important and relevant topics.

We praise the colorectal surgeonMisunderstood and much malignedSlaving away in the heart of darknessWorking where the sun don't shine

Respect the colorectal surgeonIt's a calling few would craveLift up your hands and join usLet's all do the finger wave

When it comes to spreading joyThere are many techniquesSome spread joy to the worldAnd others just spread cheeksSome may think the cardiologistIs their best friendBut the colorectal surgeon knows...He'll get you in the end!

Why be a colorectal surgeon?It's one of those mysterious things.Is it because in that professionThere are always openings?

When I first met a colorectal surgeonHe did not quite understand;I said, "Hey nice to meet youBut do you mind? We don't shake hands."

He sailed right through medical schoolBecause he was a whizOh but he never thought of psychologyThough he read passages.A doctor he wanted to beFor golf he loved to play,But this is not quite what he meant...By eighteen holes a day!

Praise the colorectal surgeonMisunderstood and much malignedSlaving away in the heart of darknessWorking where the sun don't shine!

Saturday, July 07, 2007

Some of my friends have sent me articles that are of some interest.
Standardized Patients - This Slate piece describes what the standardized patient (SP) experience is like from the SP's point of view. While comical and realistic, I hope people do not mistakenly think that medical students are all bumbling idiots. The physical exam that one is required to do on an SP is much more nerve-wracking than the ones students do all the time on patients. First off, no one really ever does a complete history & physical in real life on every patient. Second, in reality, the order is not so important as long as you cover the relevant areas. However, with SPs, sometimes they nitpick about such things, which would obviously make students more nervous than they would be otherwise. Regarding Dr. I in the piece... heh, yea, and sometimes, we med students just are bumbling idiots.

The Successful Match - This article on SDN was intriguing for several reasons. First, its central thesis is that core clinical rotation grades, not USMLE Step 1 scores, have more importance for residency matches. This intrigued me til I noticed the author names. One of them is an asst prof of dermatology at my med school. Clearly, in her case, she must have had good grades and a good USMLE Step 1 score. The article forgets that people self-select, often based on step scores. Therefore, within any specialty pool, residency directors will turn to secondary characteristics, like clinic grades. Think about it: most people applying to things like plastics or derm will already self-select and have Step scores > 240 (I'm guessing). If so, then of course directors will look at clinical grades because everyone will already have approx the same step score! Okay, I may not be completely right here, but I still think USMLE Step 1 score matters more.

How Doctors Think - A book review on NPR, this article describes one physician's questions about how doctors think. I think he raises some valid points, especially about the pitfalls of evidence-based medicine (EBM). However, I think the article actually proves the opposite point. The failure here was not of EBM itself, but its application. I find it appalling that after 15 years of a woman who is clearly having malabsorption, that no one had done an endoscopy. Even as a newly minted MS III, I could guess this woman's diagnosis halfway through the article. Sure, the article gave some big clues, but come on! The fact that this woman's diagnosis took so long is not a failure in the practice of medicine, but rather of its practitioners.

Tuesday, June 12, 2007

Funny story I heard from a friend about a med student and the Chair of the Surgery Department here... we'll call him Dr. B

The student (let's call her Amy) is a 4th year med student rotating with Dr. B for a month on the general surgery service. Dr. B is known for being very touchy-feely with his patients and listening to their issues.. you know, the "softer" side of medicine. However, he's still a surgeon and definitely has a serious side.

Anyway, the patient they are about to see on morning rounds has had many problems during her life. In addition to her surgery, she has many co-morbidities as well as stresses in her life. She has also been battling depression and weight issues. Today, her main concern is some kind of eye problem. Maybe a corneal abrasion or conjunctivitis, who knows. Dr. B and Amy proceed to talk to the patient and then perform a physical examination. Both carefully inspect the patient's eyes, conclude their visit, and quietly leave the room to discuss:

Dr. B: So, what did you think?
Amy: She has a lot going on...
Dr. B: I mean, what did you see in the patient's eyes?
Amy: Umm... sadness?

Dr. B: ...
Dr. B: What?! Go look in the patient's eyes again! What did you see IN the patient's eyes?!

Friday, June 08, 2007

Surgery has been going pretty well. I only have 6 more days of general surgery! The time has really flown by. In the few weeks I've been here, I've seen several excisional breast biopsies, some laparoscopic Roux-en-Y gastric bypasses, some Port-A-Cath insertions/removals, a laparoscopic gastric banding procedure, and laparoscopic cholecystectomy. Not the broadest variety, I know, but it was good to see the same thing done several times to see the variety / scope of the technique. I also have gotten better at suturing up wounds and feel much more confident about my manual dexterity before starting surgery. It really is like tying knots on your shoelaces... slippery, bloody knots, but still.... same idea =) What I really should be doing is studying for the surgery shelf exam!

Some drink for thought: Does a "break the seal" phenomenon truly exist? I had never heard this phrase before, but OverMyMedBody has an interesting post about whether the first bathroom episode after drinking leads to subsequent ones.